DUTY REPORT

Monday, August 12 th 2019

Opthalmologist : dr. Raja Erinda, Sp.M
Senior Resident : dr. Elly Rahmawati
Junior Resident : dr Dyah Kurniatri
IDENTITY
• Name : AKN
• Age : 25 y.o
• Address : Semarang
• MR : C770242
• Chief Complaint : blood come out from eyelid ledt eye

• Recent Medical History

• His left eye was thrown by iron rod, blood came out from eyelid (+), swollen (+), jelly
2 hours before substance came out from eye (-), redness in eye (-), pain (+)
admission

• blood came out from eyelid (+), swollen (+), redness in eye (+), pain (+)
• He was under alcohol effect
The day of • History of ocular trauma before (-), wearing googles (-)
admission
 RE LE

Visual Acuity 20/20 20/40

IOP T digital Normal T digital Normal
Palpebra Edema (-), spasm (-) Superior : edema (+), spasm (-), hematom (+) lamellar
laceration size 2x0.2x0.3 cm, active bleeding (-), excoriate
wound (+) size 1x0,5 cm
Inferior : edema (+), spasm (-), hematom (+) lamellar
laceration 0,5 cm under margo palpebral size 1,5x0,2x0,2
cm , active bleeding (-)
Conjungtiva Injection (-), secret (-), bleeding (-) Injection (-), secret (-), bleeding (-)
Cornea Clear, laceration (-) Clear, laceration (-)
COA VH grade IV, hypopion (-), hyphema (-) VH grade IV, hypopion (-), hyphema (-)
Iris Crypt (+), iridodialysis (-), iridoreksis (-) Crypt (+), iridodialysis (-), iridoreksis (-)
Pupil Round, central, reguler, Ø 3 mm, pupillary Round, central, reguler, Ø 3 mm, pupillary reflex (+) normal,
reflex (+) normal, RAPD (-) RAPD (-)
Lens Clear Clear
Fundus Reflex (+) bright (+) bright
OTS - VA pre op 20/40 : 100  Score 5  VA after 6 month fu
≥20/40 92%
• Working Diagnosis
• Left Eye Lamellar laceration palpebral superior et inferior + excoriation wound
in palpebral superior

• Management
• Suture palpebral superior et inferior
• Amoksisilin tablet 3x500mg
• Ibuprofen tablet 3x400 mmg
• Metilprednisolon tablet 8mh 1-0-1
• Chloramphenicol e.oint/8 hours left eye
• Control to polyclinic Friday, August 16th 2019